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Nasal-Septal Fractures

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Presentation on theme: "Nasal-Septal Fractures"— Presentation transcript:

1 Nasal-Septal Fractures
Francis B. Quinn, M.D. Herve’ J. LeBoeuf, M.D.

2 Anatomy Bones - Frontal process of maxilla, nasal spine of frontal bone Paired nasal bones Vomer Perpendicular plate of the ethmoid

3 Anatomy (cont.) Cartilage- Lower lateral cartilage
Upper lateral (Alar) cartilage Septal cartilage Sesamoid cartilages

4 Pathogenesis Variables- The patient’s age (tissue flexibility)
The amount of force applied The direction of the force The nature of the striking object

5 Frontal Impact Plane I- Fracture of nasal tip
Small dorsal hump with supertip depression Plane II- High fracture of nasal bones Dorsal depression Septal buckling with flattened appearance of the nose

6 Frontal Impact (cont.) Plane III-
Fracture of nasal bones, frontal process and anterior nasal spine Comminuted, lateralized Marked nasal depression Columellar retraction Medial canthal relaxation with telecanthus

7 Lateral Impact Plane I- Unilateral nasal bone depression
Elevation of contralateral nasal bone Septal buckling C or S shaped deformity of nasal dorsum

8 Lateral Impact (cont.) Plane II/III-
Fracture extension to frontal process Marked displacement of septum and dorsum Medial maxillary wall depression

9 Septal Fracture Vertical with anterior fracture
Horizontal with posterior fracture S and C shaped deformities with healing Telescoping of segments prevents closed reduction

10 History Force, direction of impact Epistaxis External deformity
Prior nasal injury, dysfunction Pre-injury photographs

11 Exam Nasal deviation Mucosal or skin lacerations Ecchymosis, hematoma
Lid edema, chemosis Subconjunctival hemorrhage Telecanthus, CSF rhinorrhea

12 Exam (cont.) Topical decongestion Debridement of clots
Internal and external palpation Exam of cartilaginous nose Roentgenograms Photographic documentation

13 Open versus closed reduction
Clinical Decisions Open versus closed reduction Closed Reduction- Unilateral or bilateral fracture of the nasal bones Fracture of the nasal-septal complex with nasal deviation less than one half the width of the nasal bridge.

14 Clinical Decisions (cont.)
Open Reduction- Extensive fracture-dislocation of the nasal bones and septum Nasal pyramid deviation exceeding one half the width of the nasal bridge Fracture-dislocation of the caudal septum Open septal fractures Persistent deformity after closed reduction

15 Clinical Decisions (cont.)
Local versus general anesthesia Timing of reduction- < 3-6 hours- immediate reduction < 2-3 weeks- closed reduction > 3 weeks- delayed 3-6 months

16 Anesthesia 4% cocaine Epinephrine soaked pledgets IV or oral sedation
EMLA cream - time consuming General anesthesia

17 Instruments Asch/Walsham forceps Large Kelly clamps
Elevators- Boies/Ballinger Various intranasal specula Headlight

18 Reduction Elevate fragment with anterolateral force
Completion of the fracture External digital molding Reduction of septum is critical Asch/Walsham forceps to elevate fracture and reduce septum

19 Trouble Shooting Overriding cartilage fragments
Post reduction instability C-shaped septal fracture Converting to an open reduction

20 Post-Op Silastic splints Intranasal placement of packing
External splint application Packing out 2-3 days, silastic-10 days External splint off when fracture stable

21 Subacute Open Reduction
Hemitransfixion, lateral intercartilaginous incisions Elevation of dorsal skin and periosteum Exposure of cartilage segments Reduction of cartilage- scoring, suture Maxillary crest involvement- “trapdoor”

22 Complicated Fractures
“Open sky” approach Use preexisting lacerations when possible Depressed comminuted fractures- wires versus miniplates Wound closure Prophylactic antibiotics

23 Delayed Repair Complicated due to scarring, fibrosis
Common problems: Dorsal hump, C/S shaped septum, saddle deformities, septal displacement, fallen or deviated tip Common solutions: Excision of hump, cartilage grafting, calvarial grafts, osteotomies

24 Children Physical differences- projection, cartilage: bone, growth centers Small fracture--- obstruction with age Edema, anxiety tend to obscure fracture Operative intervention- cosmesis, obstruction Digital compression Neonatal fracture-dislocation

25 Early Complications Septal hematoma Infections- antibiotic prophylaxis
Epistaxis- cautery, packing, ligation CSF Rhinorrhea Emphysema of the face, neck

26 Late Complications Organization of hematomas- airway obstruction
Synechia- divide if symptomatic Obstruction of the nasal vestibule Residual osteitis Malunion Naso-facial disproportion

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